CERTIFICATE OF BIRTH RESULTING IN STILLBIRTH
Certificates of Birth Resulting in Stillbirth are issued for fetal deaths of 20
weeks or more gestation that are required to be reported under
Minnesota Statutes, section 144.222.
OFFICE OF VITAL RECORDS
Stillbirth Information
First name
Middle name
Last name
Date of delivery (mm/dd/yyyy)
Sex
MN city & county where delivery occurred
___ ___ /___ ___ /___ ___ ___ ___
☐ Female ☐ Male ☐ Undetermined
Parent Information (You must provide the name of one parent)
Parent’s first name
Parent’s middle name
Parent’s last name
Second parent’s first name
Second parent’s last name
Second parent’s middle name
Requester Information
Name (Please print)
Daytime phone
Mailing Address – Street
Apt/Unit #
City
State
ZIP
Beginning in tax year 2016, parents who experience the stillbirth of a child in Minnesota may be eligible for a tax credit. To claim this credit,
parents must complete tax form Minnesota Schedule M1PSC and have a Certificate of Birth Resulting in Stillbirth. For more information
about the credit, go to the Minnesota Department of Revenue website at www.revenue.state.mn.us and search for “credit for parents of
stillborn children”, or call 651-296-3781 or 1-800-652-9094.
Signature and Notary Information (You must sign this application in front of a notary.)
I certify that the information provided on this application is accurate and complete to the best of my knowledge. I am requesting a
Certificate of Birth Resulting in Stillbirth for the child listed above. I am a parent named on the record. I understand that information on the
Certificate of Birth Resulting in Stillbirth will be shared with the Minnesota Department of Revenue for the purposes of administering the tax
credit available to parents of stillborn children.
Requester’s signature
Notary Stamp/Seal
Signed or attested before me on _______ day of __________________, 20_______
Notary public signature
My commission expires
PENALTIES: Any person who willfully and knowingly provides false information for a certified vital record may be sentenced up to 1 year in jail or a
fine of up to $3000 or both (Minnesota Statutes, section 144.227 and section 609.02, subdivision 3 and 4).
Request and Payment Information
Certificate of Birth Resulting in Stillbirth sent by First-Class Mail®
Optional: Additional certificate(s) for the same record purchased now
Number
requested
1
Fee per item
Total
$16
$16
$9 each
Optional: Rush processing
$20
Optional: Rush shipping (UPS will not deliver to PO boxes or APO addresses)
$16
Total amount submitted or to be charged to credit card:
 Check number _________  Money order number_______
 Credit Card (MasterCard/VISA/Discover)
Enter card information below
Payable to the Minnesota Department of Health
Cardholder name
Card number
3 digit security code
Expiration date
Application and credit card information may be
Mail application, credit card information or check/money order to:
Minnesota Department of Health
submitted by email to [email protected]
or by FAX to 651-201-5740.
Central Cashiering – Vital Records
PO Box 64499
St. Paul MN 55164-0499
Type of
payment:
If you have questions, please contact the Office of Vital Records at [email protected] or 651-201-5970.
2/2017